EBCOG Hospital Recognition: where do we stand?

Hospital Recognition for general Ob/Gyn training programmes was started by EBCOG (European Board & College of Obstetrics & Gynaecology) in 1996 and for subspecialty Ob/Gyn training programmes in 2005, the latter jointly with the four European scientific organisations representing the subspecialties. So far, 85 Audits/Visits have been -conducted by EBCOG for general Ob/Gyn training and a good start has been made for subspecialty training, in particular-- Gynaecological Oncology. EBCOG Visits are conducted by two EBCOG representatives and one trainee appointed by ENTOG (European Network for Trainees in Obstetrics & Gynaecology) for general Ob/Gyn training -programmes and by two subspecialty specialists and an EBCOG representative for subspecialty programmes. Each Visit lasts one day. Accredition is granted by the EBCOG Executive Board depending on the Visiting report. Ultimately, EBCOG would like to see the introduction of an auditing and accreditation system for general and subspecialty Ob/Gyn training programmes in each country in Europe.

Introduction

Medical specialist training is subject to continuous changes ranging from progress in diagnostic and treatment modalities, shorter working hours (European Working Time Directive) and gender shifts to changes in doctor-patient relationships, perceptions of patient safety and litigation. Whilst we live in one united Europe, we have to appreciate there are cultural differences in medical practice, differences in organisational structures and responsibilities, differences in resources and differences in perceptions of quality of training. Standardisation of medical specialist training in Europe is, therefore, not feasible. We can only strive for harmonisation of training at best.

1. EBCOG and Ob/Gyn training

The main objective of EBCOG (European Board & College of Obstetrics & Gynaecology) is to improve the health of women and their babies by promoting the highest possible standards of care in all European countries (www.ebcog.org).

As for training, the EBCOG mission is to harmonise postgraduate training in Obstetrics & Gynaecology in Europe at the highest possible level in order to provide optimal health care in all areas encompassed by the definition of the specialty. From this follows that fully trained Ob/Gyn specialists should be competent to practice without supervision anywhere in Europe. Based on the above mission statement, EBCOG initiated two training-related activities at the start of the organisation in 1996. The first one being the EBCOG Standing Committee on Training & Assessment responsible for introducing minimum requirements for training and a logbook for general and later subspecialty training in Obstetrics & Gynaecology. The second activity involved the introduction of EBCOG Hospital Recognition which focuses on visiting/auditing and accrediting general Ob/Gyn training programmes and recently also subspecialty Ob/Gyn training programmes.

2. EBCOG Hospital Recognition for general Ob/Gyn training programmes

2.1. What are the objectives?

First and foremost, it is aimed at improving, assuring and assessing the quality of specialist training in raining hospitals throughout Europe. It also aims to stimulate National Societies of Obstetrics & Gynaecology to introduce their own hospital visiting system.

2.2. What are the benefits?

Its benefits should be clear: The introduction of hospital visiting should lead to an improvement of the structured process of training, the uniformity and assessment of training and ultimately harmonisation of training in the specialty throughout Europe.

2.3. What is the focus of the Visit?

The Visit lasts one day. An interview is held with the Head of Department and senior staff about the training programme, hospital infrastructure and tutorships. A considerable amount of time is spent with the trainees to learn about their experiences and perceptions of the quality of training provided to them on a daily basis.The focus lies on the structure of training; the various rotations; the logbook; tutorship; skill-related and theoretical training; patient safety; involvement in basic/clinical research; and working hours.

A meeting also takes place with a senior staff member of the Department of Neonatology and Department of Anaesthesiology as both Departments play a role in Ob/Gyn training.

EBCOG believes that training-related auditing cannot be complete without some degree of practice-related auditing. The Visit would, therefore, include looking at the way the specialists function as a group in the day-to-day provision of patient care, the management of care processes and the position and performance of the department in the total hospital context. Depending on who is ultimately responsible for remuneration and legal aspects regarding trainees, a meeting is arranged with the Hospital Director or the Dean of the Medical Faculty.

At the end of the Visit, preliminary conclusions and recommendations are drawn up and presented to the Head of Department and the senior staff. The final report of the Visit is presented to the EBCOG Executive Board for either approval of accreditation for a maximum period of five years or a revisit after one or two years depending on the time needed to remedy certain major training deficiencies.

At the start of the training each trainee should be given a copy of the national training programme with its syllabus and defined requirements for practical skills and theoretical knowledge. This would create a goal rather than a time-orientated process.

The trainee should be properly assessed at the completion of each rotation. This includes not only the assessment of practical skills but also progress in theoretical knowledge and attitudes towards patients.

The present master/apprentice system should be supplemented with a tutor/mentor system. A majority of staff would need to be involved in regular supervision of the trainees in a preferably one-to-one relationship, which includes the full use of the logbook.

Well-defined end points (targets) are required for all Ob/Gyn procedures to assure adequate clinical competence at the completion of the training period (not only numbers).

Structured/theoretical training should act as an integrated part of the training programme.

Employment contracts should cover the entire training period of five years.

Working day and out of hours work patterns and rotas must be clear, comprehensible and EWTD (European Working Time Directive) compatible.

2.5. Who conducts the Visit?

The Visit is conducted by two colleagues familiar with the visiting process and appointed by EBCOG as well as one trainee appointed by the European Network of Trainees in Obstetrics & Gynaecology (ENTOG). The latter plays an essential role during the meeting with trainees at the time of the Visit. As for the EBCOG Visitors, it is aimed at having one of the Visitors from the country where the Visit takes place. This would contribute to the learning curve in those countries with as yet no auditing and accreditation system in place.

2.6. Who pays for the Visit?

The two EBCOG Visitors and ENTOG representative are reimbursed for travelling (economy class) and accommodation up to a maximum of two nights by the Department requesting the Visit.

2.7. How to apply for an EBCOG Visit?

A request has to be made to the co-ordinator of the Hospital Recognition Programme: Prof Juriy Wladimiroff (e-mailaddress: j.wladimiroff@btinternet.com).

Forms will be sent to the applicant to be completed. There is one form for the Head of Department and one form for a trainee. Both forms should provide basic information regarding the departmental structure, the training programme, tutorship, the logbook, practical skill-related activities, theoretical teaching etc.

3. EBCOG Hospital Recognition for subspecialty Ob/Gyn training

Visiting/auditing of subspecialty training programmes was started in 2005 as a joint undertaking of EBCOG and the European scientific organisations representing the four Ob/Gyn subspecialties. The latter are the European Association for Perinatal Medicine (EAPM), the European Society for Gynaecological Oncology (ESGO), the European Society for Human Reproduction and Embryology (ESHRE) and the European Uro-Gynaecological Association (EUGA). This co-operation has resulted in four sub-specialty training programmes and one EBCOG Subspecialist Sub- committee (SSSC). These programmes work the same way as those for general Ob/Gyn training. The Visit is conducted by two colleagues appointed by one of the above-mentioned European scientific organisations responsible for a particular subspecialty and an EBCOG representative.

ENTOG is not involved in this programme as trainees (fellows) in any of the subspecialties are fully licensed for general Obstetrics & Gynaecology.

Accreditation is granted by the EBCOG Executive Board having heard the opinion of the subspecialty representative and the Chair of the SSSC based on the Visiting report.

Applications can be made to either the representative of the relevant European Scientific Society who has a seat on the Executive Board of EBCOG (EAPM: Prof C. Sen: csen@cihatsen.com; ESGO: Prof G. Gitsch: gerald.gitsch@uniklinik-freiburg.de; ESHRE: Prof B. Tarlatzis: tarlatzis@hol.gr; EUGA: Prof M. Halaska: michael.halaska@fnb.cz) or the Chair of the EBCOG SSSC (JW Wladimiroff). It essential though that application for a subspecialty Visit can only be made following accreditation for the general Ob/Gyn training programme either by EBCOG or a national auditing and accreditation authority within the last five years.

An increasing number of Ob/Gyn departments already accredited for their training programme(s) in European countries with a national auditing and accreditation authority in place has also requested EBCOG recognition of its general or subspecialty training programme. EBCOG agrees that Departments accredited by their national accreditation authority should also have the opportunity to be accredited by EBCOG in co-operation with the National Ob/Gyn Society of those countries with an auditing and accreditation system to ensure this would meet their approval. All European National Ob/Gyn societies are currently being consulted on this issue.

3.1. Stand Alone Centres versus Independent Units

An important prerequisite for a responsible subspecialty auditing and accreditation programme is the coverage of the entire subspecialty training programme by the department applying for a visit. Subspecialty training is sometimes provided in so-called stand alone centres. These are centres which geographically and administratively act independently from a general Department of Obstetrics and Gynaecology, but cover the entire subspecialty training programme. Stand alone centres in Gynaecological oncology serve as an example (Cancer centres). A stand alone centre should be allowed to request subspecialty accreditation.

On the other hand, an independent unit provides training in a specific area of the Ob/Gyn subspecialty.

Examples are: Ultrasound units and IVF units. An independent unit can not obtain separate accreditation for its subspecialty training programme.

However, an independent unit can participate in subspecialty training as an integrated part of a sub-specialty training programme under the auspices of and run by a Department of Obstetrics and Gynaecology which has been accredited for general Ob/Gyn training by EBCOG or an official national body. This implies that a hospital Visit for subspecialty accreditation will include both the independent unit and the Department of Obstetrics and Gynaecology responsible for the subspecialty training programme.

4. What has been achieved so far?

So far 85 EBCOG Visits have been carried out for general Ob/Gyn training programmes in 19 European countries (Tables 1a, Table 1b), including eight re-visits for re-accreditation (Czech Republic; Hungary, Slovenia and Switzerland) The entire EBCOG Hospital Recognition Programme is based on voluntary applications. This would allow departments to get acquainted with the principle of auditing, but should ultimately lead to the set up of national auditing and accreditation authorities. Countries like Sweden, Denmark, United Kingdom, Ireland and The Netherlands already had a national auditing and accreditation system in place before the start of EBCOG Hospital Recognition. Experience from these countries was used getting the programme off the ground. Norway, Finland, France and Portugal are countries which now have their own national auditing and accreditation system for general Ob/Gyn training programmes following a series of EBCOG Visits. Recently, the Flemish Society of Obstetrics and Gynaecology (VVOG) has decided to introduce a hospital recognition programme for the Flemish part of Belgium. A central European consortium is being created representing the Slovak Republic, the Czech Republic, Hungary and Slovenia to gradually introduce a joint auditing and accreditation system under the auspicies of EBCOG. Auditing of subspecialty training programmes is still in its infancy. ESGO has made enormous progress with 23 completed visits so far. The other subspecialty organisations also have started the auditing process, they are keen to participate (Tables 1a, Table 1b).

Table Ia.

Number of Departments per country accredited by EBCOG for general obstetrics and gynaecology and/or for one or more of the subspecialty training programmes (EAPM, ESGO, ESHRE, EUGA). About 9% of the accreditations for general obstetrics and gynaecology training programmes are re-accreditations after a period of five years.

COUNTRY	GENERAL OB/GYN	ESGO	EAPM	ESHRE	EUGA
NORWAY	1	1
FINLAND	4
UNITED KINGDOM	0	2	2
NETHERLANDS	2	1
BELGIUM	5	1		2
FRANCE	10	1
SPAIN	1
PORTUGAL	3
GERMANY	17	10			1

Table Ib.

Number of Departments per country accredited by EBCOG for general obstetrics and gynaecology and/or for one or more of the subspecialty training programmes (EAPM, ESGO, ESHRE, EUGA). About 9% of the accreditations for general obstetrics and gynaecology training programmes are re-accreditations after a period of five years.

COUNTRY	GENERAL OB/GYN	ESGO	EAPM	ESHRE	EUGA
DENMARK		1
SWITZERLAND	2
AUSTRIA	2	2
ITALY	9
SLOVENIA	3
CZECH REPUBLIC	7	2			2
SLOVAK REPUBLIC	1
HUNGARY	7
CROATIA	1
GREECE	4	1	1	1	1
TURKEY	6	1	1	1

5. How to further the principle of auditing general and subspecialty Ob/Gyn training programmes

Up until now auditing Ob/Gyn training programmes as organised by EBCOG has been a positive experience for the vast majority of Departments visited. To translate a handful of EBCOG audits into a national auditing and accreditation system clearly takes time. Specialist training may not be the sole responsibility of the National Societies of Obstetrics and Gynaecology but shared with the local government, notably the Ministry of Health or Education. However, in the end it is at national level that our profession should take the necessary steps for the introduction of a regulated assessment of the quality of training programmes in training hospitals.

Representatives of member countries in the EBCOG Council as well as the representatives of the European societies for the four subspecialties in the Executive Board of EBCOG are in a unique position to play a pivotal role in this endeavour. In the mean time, EBCOG will continue with its Hospital Recognition programme to further acquaint European countries with the principles of the Visiting system.